An open-source electronic health record system developed to treat Ebola patients during the recent epidemic in West Africa is being touted as a potential solution for clinical data collection in highly infectious environments and resource-constrained healthcare settings.
Implemented two years ago at Save the Children International’s Kerry Town Ebola treatment center in Sierra Leone, the EHR leverages a Java-based web application called OpenMRS that enables the design of a customized medical records system with no programming.
Developed in less than three months, OpenMRS-Ebola consists of a modular stand-alone EHR system with a tablet-based application for infectious patient wards (red zone) and a desktop-based application for noninfectious areas (green zone). The Sony Xperia Z2 10.1-inch tablet was selected for the EHR because it was waterproof and could be disinfected with chlorine.
Features of the system include the ability to support patient tracking, record vital signs and symptoms, order medication, show laboratory results, as well as writing clinician notes and exporting data.
A paper describing OpenMRS-Ebola was published this week in the Journal of Medical Internet Research.
“In the red zone, the user interface was optimized for readability, speed, and ease of use by users wearing personal protective equipment,” according to the article’s authors. “We designed the tablet UI for portrait mode because users found it easier to hold the tablet vertical when using one hand.”
Shefali Oza, lead author of the article and an epidemiologist at the London School of Hygiene and Tropical Medicine, says that initially when she and others with Save the Children went to Sierra Leone to set up the Ebola treatment center, they considered a paper-based system for recording and reviewing patient data on site. However, they soon decided what was needed was an inexpensive EHR that could be very quickly adapted with an easy-to-use and deploy tablet interface.
OpenMRS, a free platform based on open standards designed to share information and reduce effort, fit the bill. “We needed something that was tested and used in low-resource settings,” says Oza, who notes that the EHR software supported by a global community of volunteers has been leveraged in developing countries battling AIDS, tuberculosis and malaria.
“You always want software to be easy to use, but that was more important than ever for clinicians wearing head-to-toe protection,” she adds. “One of the key requirements was that it had to be incredibly easy to use. And, because we were developing it during a health emergency, we wanted it to be as intuitive as possible, given that we wouldn’t have much time to train staff before using it.”
Nearly 100 clinicians were trained to use the system from January to March 2015. In total, 112 of 456 Kerry Town ETC patients in Sierra Leone were entered into OpenMRS-Ebola.
Jonathan Teich, MD, an emergency physician at Brigham and Women’s Hospital in Boston, helped to develop the user interface for OpenMRS-Ebola.
“OpenMRS is a remarkable organization that does electronic health records around the world trying to bring this kind of clinical functionality to these systems which are used in low- and middle-income countries around the world,” says Teich, who adds that having robust infection prevention and control measures was critical for Ebola treatment centers in Africa.
“You have to make something that is very usable for people who are wearing double gloves, face protection and goggles,” he observes. “They can’t see very well and they can’t touch very precisely and you have to make something that is easy to learn and can be operated quickly because they have about two minutes per patient on rounds.”
Teich notes that the team worked closely with clinicians to determine the important data they needed to capture and view at the bedside, and then built those optimized functions into OpenMRS-Ebola. The protective equipment constraints of working in a highly infectious environment had a “very beneficial side effect—essentially, because we had to make it fast and easy to use, we did,” he says.
For example, an entire patient symptom profile could be captured on a single screen in less than a minute using the tablet-based app, according to Teich.
“Pushbuttons had to be made big enough to push wearing all of those gloves,” he adds. “We also made it possible to order medications in a few seconds each and review someone’s intravenous fluids in maybe three clicks total. So, you really focus on what’s important in this particular refined environment.”
OpenMRS-Ebola was developed “on the fly by 10 people in nine different time zones” to address a specific need for an EHR during the 2014-2016 West African Ebola epidemic, Teich says. However, he contends that the system could be used for future public health emergencies. “It might be a different illness next time, but these rapid interfaces and software make it suitable for other outbreaks—we want to be ready for the next one.”
Likewise, Oza believes that “we can’t wait until the next emergency” and the “work needs to start now” in order to be prepared. While it only took two and a half months to develop OpenMRS-Ebola, she says software requires “thoughtful development” to meet future contingencies.
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